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Environmental Health Department <br />Lie. Plate # <br />Date. <br />3 <br />2. <br />Owner/Operator Gt . j. <br />and meets the California Health & Safety Code requirements <br />• r • _ - ■ -, — — x III On <br />Date <br />REHS Signature. <br />are available at the <br />L/G.q- <-1 S-70 <br />4^ Electrical hook-ups <br />.X Toilet and handwashing <br />^E( Potable water <br />Vehicle wash <br />hereby state that the information I have provided is current, true and <br />--------------*3. |f the food facility <br />if this agreement is modified or cancelled, the <br />1868 E. Hazelton Avenue ] Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 (www.sjgov.org/ehd <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete sectio <br /> pMfOeicSiietegby APPLICANT ______~ <br /> Business <br />Owner/Operator Name -----A \ — <br />Business Mailing Address—, 57 9 I 9 <br />City StateC IT Zip^ S 7OS_Bus. Ph.------------------------------Alt- Ph^ <br /> <br />I. ■. hereby State that^eabo^info^ati^is current^ to <br />the best of my knowledge and^^ze -V aPProve^00^.3^ n^coo^nce^^ <br />commis^an^is^iscontinued^'the pShX must notify the EHD. Failure to notify this office may result in permit <br />revocation and penajties. —. 2/p — <br /> Signature <br />\ SAN JOAQUIN <br />-----COUNTY----- <br />■.v'-v Greatness grows here. <br />fileted by COMMISSARY OWNER/OPERATOR__ <br />Commissary Name Lb.___C 0 Y'r'igT C' C*. I-----FA <br />Address. 7.Iii 06 £• VUr d tn^ ^5-------Bus' Phone ^C'<'y <br />City 4->tocilfon______Zip S ------< <br />Check all appropriate services provided: <br />Hx3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />15 Overnight parking <br />Wastewater disposal <br />Solid waste disposal <br />cEt Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I, jf\ <VGc ---- <br />correct to the best of my knowledge, <br />operator fails to comply with the conditions of this agreement, or <br />commissary owner shall notify^he EHD immediately. <br />Signature__________.X—----------------------- -—_____ _____ ____ <br />3 To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. . <br />County. The above food facility meets the <br />SmXTrXXt in' California HealtrT»^-T^bove checked services <br />above commissary. Please notify EHD if the status of their operating perm.t changes. <br /> Date _